Establishing an Advanced Illness Management (AIM) Model in a Community-Based Setting

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1 Establishing an Advanced Illness Management (AIM) Model in a Community-Based Setting Health Care Workforce for Older Americans: Promoting Team Care October 7, 2008 Panel on Models of Team Care for the Functionally Impaired and Nursing Home Eligible Penny Hollander Feldman, Ph.D. Director, Center for Home Care Policy and Research 1

2 Project Team Penny H. Feldman, P.I. Director, Center for Home Care Policy & Research Mary Jo Vetter, AIM Co-Director Director, Centers of Excellence & Education Managed Care New Clinical Product Development Jeanne Dennis, AIM Co-Director Director, VNSNY Hospice Care Marian Haas, AIM Co-Director Director, Human Resources Clinical Team Marilyn Liota, Regional Administrator, VNSNY Queens Geraldine Abbatiello, Advanced Illness Management APN Karol DiBello, Advanced Illness Management APN Funding: New York State Health Foundation 2

3 Context VNSNY Established 1893 Largest nonprofit home care organization in U.S. Serves NYC metropolitan area ~31,000 average daily census; ~120,000 patients annually, ~86 service delivery teams, ~2500 nurses, ~650 therapists, ~650 social workers, ~6000 aides Home Health Care U.S. Post-acute & long term care ~8000 Medicare-certified home health agencies (3.3 million discharges in 2005) Older persons = 85% of home care episodes; multiple chronic conditions; multiple medications; frailty; cognitive impairment Team-based service delivery (nurses, therapists, social workers, and aides) Dispersed, generalist nursing workforce Few APNs, little geriatric or palliative care training 3

4 Advanced Illness Management (AIM): The Problem and the Opportunity Problem: Intense, acute care in advanced stages of illness Does not necessarily = better quality of life or reduced morbidity Does = high Medicare costs, potential misallocation of resources : Medicare Spending last 6 months of life (Dartmouth Atlas, 2006) U.S. Hospital days per Medicare enrollee. = 11.7 days NYS Hospital days per Medicare enrollee = 16.9 days (more than residents of any other state save Hawaii) U.S. Hospice use rate = 27% NYS Hospice use rate = 18.7% Medicare spending on chronically ill decedents, last two years of life (Dartmouth Atlas 2008) All U.S. Hospital Regions = $46,412 NY (Manhattan & Bronx) = $81,143 Goal: Create a cost-effective model of advanced illness & palliative care that improves quality of life and appropriateness of care for patients with advanced chronic illness 4

5 Interdisciplinary Team-Based Care Evidence reviews show that multidisciplinary team-based interventions have been key to promoting comprehensive, person-centered palliative and EOL care (Francke, 2000; Lorenz, 2008; NQF, 2006; WHO, 2004) 5

6 VNSNY AIM Program: Objective 1 Embed home-based palliative care into routine practice of the home care team: Build team capacity for an interdisciplinary approach to advanced illness management Deploy APN, MD, SW to direct, guide and support Designate AIM Clinical Resource Nurse (CRN) for each service team Develop collaboration between CRN, primary nurse, hospice & patient/family Prepare/implement collaborative, individualized AIM plans: advance care directives, ED alternatives, palliative care, hospice referral 6

7 Building Team Capacity for Advanced Illness Management *Roles of Team Members Frontline service manager addresses CRN assignment and caseload issues CRN collaborates with primary nurse on AIM plan of care Primary nurse follows up with patient, family, and primary care physician on AIM plan of care Social workers, therapists, and aides provide additional support to patients as needed 7

8 VNSNY AIM Program: Objective 2 Develop a clinical career path for frontline nurses that can be broadly replicated by Medicare/Medicaid certified home health agencies (CHHAs): Develop an advanced clinical position for generalist homecare RNs who generally lack clinical career opportunities in traditional CHHAs Provide CEU-eligible trainings on how to: Assess patients for advanced illness management and palliative care needs Manage pain and non-pain symptoms Communicate about advanced illness and goals of care with patients, caregivers, collaborating nurses, and physicians Provide ongoing mentoring and clinical support to CRNs by a palliative care-certified APN 8

9 Program Development and Training Development & Planning: AIM protocols, assessment tool, roles & responsibilities, electronic patient screening/tracking system, training curriculum Clinical Resource Nurse (CRN) Training & Support: 12 hours of training in advanced illness management provided by 2 APNs specializing in palliative care (eligible for CEUs) APNs shadowed CRNs making visits to AIM patients during initial training phase Clinicians on 5 service teams received instruction on collaborating with CRNs assigned to their teams Ongoing one-on-one mentoring by APNs Regular case conferences with Hospice clinicians 9

10 AIM CRN Workforce 13 nurses trained as CRNs Tenure at VNSNY ranges from 2 28 years Average of 10 years Diverse educational backgrounds 3 BSN-level nurses 6 MSN-level nurses 3 Nurse Practitioners 1 AIDS certified RN Languages spoken: Greek (1), Tagalog (3), Chinese (1), Korean (3), Polish (1), English only (4) 10

11 Patient Eligibility Criteria for AIM Program Risk algorithm: Patients must meet 1 of these 3 criteria: A. Life expectancy < 6 months AND either poor overall prognosis or poor rehabilitation prognosis OR B. Poor prognosis AND a primary diagnosis of 1 of the following diseases with severity of 3 or greater: Malignant neoplasm, Heart failure-chf, Ischemic heart disease, HIV, Renal Failure, Hepatic Failure, COPD, Parkinson's, Multiple Sclerosis, ALS, Huntington's, and Alzheimer s (for Alzheimer s only, severity must be 4) OR C. A primary or secondary diagnosis of one of the diseases listed above with severity of 4 11

12 AIM Implementation Implementation: December 2007 to date 13 CRNs designated, trained and receiving ongoing mentoring ~100 field nurses received one-hour initial training on advanced illness management and continue to receive updates and support through CRNs 304 patients have received AIM services Anticipated patient sample Total of 350 patients will receive AIM services during a 1-yr period 350 control patients Patients served by usual care teams who meet AIM screening criteria during the same timeframe 12

13 First 200 AIM-Eligible Patients (Intervention Group): Demographic Characteristics Age in years, mean (SD) Female, % (N) Lives Alone, % (N) N=200 Percent/Mean 73.8 (14.2) 52.5 (N=105) 27.5 (N=55) Race, % (N) White Black Hispanic Asian Other 53.0 (N=106) 14.5 (N=29) 17.0 (N=34) 15.0 (N=30) 0.5 (N=1) Language Spoken, % (N) English Spanish Other 64.5 (N=129) 14.5 (N=29) 21.0 (N=42) Payor Type, % (N) Medicare FFS Medicaid FFS Dually Eligible Managed Care Referred from Hospital, % (N) 53.5 (N=107) 3.0 (N=6) 21.5 (N=43) 30.0 (N=60) 72.0 (N=144) 13

14 First 200 AIM-Eligible Patients (Intervention Group): Demographic Characteristics N=200 Percent/Mean Life Expectancy Less than 6 Months, % (N) 55.0 (N=110) Poor Prognosis, % (N) 93.8 (N=180) Number of Illnesses (range 0-5), mean (SD) 4.2 (1.0) Number of Medications Taken at Admission, mean (SD) 8.5 (4.1) Number of ADL Assistance Needed, range 0-8, mean (SD) 7.1 (1.7) Number of IADL Assistance Needed, range 0-6, mean (SD) 5.4 (0.7) End-Stage Diseases, % (N)* Cancer Congestive Heart Failure Chronic Obstructive Pulmonary Disease Other End-Stage Disease (e.g. Ischemic heart disease, HIV, Renal failure, Liver failure, Parkinson's, ALS, Multiple Sclerosis, Huntington's, Alzheimer's) 29.5 (N=59) 12.5 (N=25) 12.0 (N=24) 9.0 (N=18) *These end-stage diseases do not account for 100% of sample. Roughly 38% of sample met AIM criteria based on life expectancy alone, regardless of diagnosis. 14

15 Goals of the AIM Evaluation Assess the impact of AIM on patient outcomes: Referral to hospice Emergency care utilization and hospital admission Symptom control and quality of life Documentation of advance care directives Assess the impact on nurse outcomes: Awareness of palliative care Perceived career opportunities and job satisfaction Further develop the CRN role as a career development opportunity; formalize the role within VNSNY staffing and team structure Analyze AIM s effect on agency costs and cost-effectiveness Understand challenges and identify strategies for implementing/replicating AIM throughout VNSNY s regions and home health agencies nationwide 15

16 AIM: System Challenges Systems and Attitudes: Reaching short-stay patients covered by managed care Initiating & implementing individualized AIM plan before unstable patients cycle back to the hospital in first week of care Enlisting the support of families & primary care physicians Changing organizational productivity expectations Resources: Establishing a firm mechanism to pay for Advanced Practice Nurses Adjusting productivity standards for Clinical Resource Nurses Addressing externalities 16

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